A Brush Up on Clinical Documentation: A Clinician’s Considerations

California Society for Clinical Social Work
THE CLINICAL UPDATE | SUMMER 2019

A Brush Up on Clinical Documentation: A Clinician’s Considerations

By Elizabeth Irias, LMFT

We therapists and social workers are told time and time again that our notes are legal documents, yet we often receive very little training about what actually needs to be in them. Further, there are a number of myths that float around the therapist community that can get providers into serious legal trouble (for example: "Notes need to be short and vague to protect client confidentiality,” or, “Clinicians in private practice don’t really need to keep notes”). Many therapist do not realize that inadequate documentation can have grave consequences, including threats such as loss of licensure and even time behind bars, not to mention the potential negative impact on our clients. With all of the responsibilities facing busy clinicians, clinical documentation often becomes an afterthought, though it behooves us to stay on top of our records, as a service to ourselves, our practices, and our clients. Let’s take a few minutes to review some California laws and standards, and their impact on our clinical documentation…